Why Belgium has the highest coronavirus death rate in the world

Doctor speaks to patient in the coronavirus unit at the Erasme Hospital in Brussels: AFP via Getty Images

It is rare for Donald Trump to credit other countries with world records, but at a press briefing last month the US President unveiled a list that put Belgium at the top. Unfortunately for Belgium, it was a ranking of deaths from the coronavirus. According to numbers collated by the Johns Hopkins University, Belgium leads the world in deaths per head of population, with the latest count on Friday showing it at 665 per million. By comparison, Britain’s rate is 394, the US’s is 193, Spain’s is 525, and Italy’s is 463. So why is Belgium’s relative death toll so high?

In many ways, Belgium was well protected to weather the virus storm: it moved relatively swiftly to impose lockdown restrictions and its healthcare system is recognized as one of the best in the world. Yet as of Friday, it had recorded a total of 7,703 coronavirus deaths and 49,032 cases. In absolute fatalities, Belgium is in sixth place worldwide. Germany, next door, has registered just 6,632 deaths, but it has a population of 83 million, compared to Belgium’s 11.5 million.

But Belgium’s high numbers have less to do with the spread of the disease and more to do with the way it counts fatalities. Its figures include all the deaths in the country’s more than 1,500 nursing homes, even those untested for the virus. These numbers add up to more than half of the overall figure.

Belgian Prime Minister Sophie Wilmés says the government chose “full transparency when communicating deaths linked to Covid-19,” even if it leads to “numbers that are sometimes overestimated.” Health Minister Maggie De Block says Belgium is setting an example in diagnosing the disease. “In Europe, no country counts like the others. We have the most detailed method,” she said.

As the World Health Organization (WHO) points out, measuring mortality is tricky as clinicians have to determine if Covid-19 is a contributing or an underlying cause of death, and countries have different ways of issuing death certificates. But other countries are now adding care home deaths to their overall tally, including Britain – although the UK does not go as far as including those not confirmed by tests.

Steven Van Gucht, the head of the viral disease division at the Sciensano public-health institute, says he is not bothered by charts showing Belgium at the top. “If you want to compare our numbers with other countries, then you have to divide it by two,” he says. Mr Van Gucht, who is also a virology professor at Ghent University, says the measure also helped increase political pressure to do more in care homes. “We do this because we want to save lives. In that way, the system worked,” he says.

But the system is controversial, as it means deaths from diabetes, heart failure, hypertension and other problems are included in the Covid-19 tally. Virologist Marc Van Ranst, from Leuven University (KUL), has described it as “stupid” because it gives the impression that the coronavirus is the only cause of death in care homes.

Belgium’s decision also showed how exposed elderly people are. Vincent Fredericq, the director-general of care home federation Femarbel, says the elderly were left behind in the rush to prepare hospitals. “They saw what happened in Italy and how their hospitals were overwhelmed. So there were instructions to hospitalize people from care homes as little as possible,” he says. “We were treated like the second class. And in the end, the hospitals were not overwhelmed – they actually had spare beds available in the intensive care units.” Indeed, even at the disease’s peak in Belgium, in early April, ICUs were only at 57 per cent capacity.

Belgium is now testing the more than 240,000 residents and staff at nursing homes, and the early figures show a 9 per cent infection rate for care home residents and 4 per cent for personnel. But Mr Fredericq admits that it is hard to predict how many people died from the coronavirus in care homes. “The average age of residents is 85-86, and their average stay is just 16 months. There is an inevitable high mortality, so they could have died anyway,” he says.

Belgium also benefits from a relative political calm, and firm popular backing for the prime minister: Mrs Wilmés is widely praised for her calm, clear and reassuring leadership. Scientists, like Mr Van Gucht, lead the daily briefings, not politicians. And Belgians generally comply with the restrictions, despite the occasional ‘lockdown parties’.

Mr Van Gucht says that Belgium’s measured response was even helped by the country’s notoriously fractious party politics. “Yes, the political landscape is divided and diverse, but that made the politicians more willing to listen to expert scientific advice,” he says. But he does believe that geography may have raised the numbers: not only is Belgium a densely populated country, but it is at the crossroads of Europe and its capital Brussels is a very international city.

Officials now believe that the main wave of infections came from Italy in the last week of February. “We were hit hard and suddenly in carnival holidays,” says Mr Van Gucht. “Italy is very popular with Belgians at that time of the year: the food is good, the ski is good, and you can go by car. We know it came from there because when we checked the genetic sequences, there were multiple interactions in Italy.”

Belgium now seems to have flattened the curve: on Friday, it reported 130 fatalities overall (83 in care homes), and 513 new cases. The first phase of Belgium’s exit from the lockdowns will begin on Monday, with certain shops re-opening, and if the numbers stay low, schools will restart later this month.

As for the charts, Belgium may stay at the top for a while. But Mr Van Gucht insists the method was the only honest way to do it. “History will show that Belgium got its numbers straight – that is the only thing the charts show,” he says.